Good afternoon, everyone. Thanks for joining us for the EP lab billing for physicians, the least you need to know, we'll get started in just a little bit. I'm going to give everyone just a couple of minutes to get logged in and transitioned into the zoom. And I would add that if you're on the phone only, and you have the ability to see the slides, it would probably be very helpful because I'm, I'm not one for reading slides much. So you might want to be able to see them. Absolutely. And we will have a recording of the session that's available for your teams to listen to. And that's usually available pretty quickly. And the slides are available as well as a handout. So we'll talk about that a little bit as well. All right. Well, we're going to go ahead and get started. My name is Nicole Knight, and I'm the executive vice president of MedAxium Revenue Cycle Solutions and part of the care transformation team. I'm joined by Linda Gates Shribby, who's also a consultant with MedAxium and has been part of MedAxium for a very long time. She's also the director of quality assurance at Ascension Medical Group in Indiana. Many of you know Linda. So we're happy to have this web today and just a couple of housekeeping items. On your Zoom control panel, there is a chat button. The chat button is where you will have a link to the slide presentation where you can download it and save in a PDF format. And then like I mentioned, there will be a recording of this session to be listened to at a later date. That'll be available in our academy website as well. The Q&A button is where you can type questions in as we go through the session. And we encourage you to be very interactive as we go through. Particularly if you're in a room with several people as opposed to listening to this individually, it'd be great for us to be able to know the name of your organization. And if you're in a conference room and there's multiple folks listening, we'd love to hear that and know where you're listening from. So feel free to enter that in the Q&A as well. If you are in a room with physicians and coders, we always love that collaboration and think it's very important. This webinar is geared towards our physicians and there are no coder CEUs for this webcast or no CMEs. This is just an educational format for our EP physicians in regards to coding and documentation. So we're going to cover a review of the EP studies and ablation services, the coding and documentation, what's bundled versus billable, documentation tips for those add-on services with ablations. We're going to get into the device procedures after we go through those services and talk about the four categories and also look at what are those add-on services and what's bundled versus billable. So this will be driven towards what's included but really focused on what's the practical documentation tips and what we see in these areas that's relevant to what you're doing on a day-to-day basis in the EP world. So Linda, I'm going to kick it off to you. Get started. Great. Thank you, Nicole and welcome everyone. I'm so happy to be able to do this. So thank you for joining and as Nicole mentioned, I think we're going to be speaking to the physician audience here but it's wonderful if you're all in a room together or a couple of you or the physician and the coder and if not, the fact that you can download this and listen to it then together or talk through it together is wonderful. So we'll start off with just your basic EP study. You'll notice there are two coding options there on the screen, the 93619 as well as the 93620. The only distinction here is whether or not you try to induce an arrhythmia. So whether you successfully induce an arrhythmia or not is completely irrelevant. You'll notice in the red type and highlighted there, it's with an attempted induction. So I see that sometimes coded incorrectly with people saying, well, but we didn't induce an arrhythmia. Well, you don't have to. You have to just try in order to build the 620. Now, anytime that you're doing just the EP study and you're not going on to then include an ablation, that's when you want to be looking at those other elements there on the left-hand side. Now, of course, as you see in the longer code description, anytime you're building that EP study, it's assuming that you are doing a pacing recorder from the RARB as well as a HIS record. The elimination of any one of those, if for whatever reason you can't do that, then you want to say that, but you'll see that it says, you know, when performed. Now, in the event that you're not doing all three, that's when you would put together those codes on the left there and use those to describe what was done that day, coding each of those individually. But, you know, 99% of the time, it's going to be one of those comprehensive codes. Next slide. So if we look at, you know, what we've seen and we've got each of these add-on codes, you know, it used to be that we would build that EP study and then we would start adding each of these codes to describe what else was done in that study until we've fully described everything. So these codes are still available and when you can use them and when you can't is going to be dependent upon, you know, what do you do next. So if you do that EP study, everything you see listed here can add on to the EP study, but if that EP study turns into an ablation in the same session, well, that's when we're going to talk about which of these individual services are now bundled into that ablation versus which ones are still separately billable. One of the things I see on the 93621 that, you know, if you, I would caution and hope that all of you as physicians play some sort of role in ultimately coding these cases, whether there's a bill that you check off or, you know, if you're writing something down so the coders can help it because that first one, the 93621, you know, you can see that it says a left atrial pacem record from the coronary sinus. Well, I've seen beginning coders not understand that when you say something like the LA cath, that that is in the coronary sinus. If you went into the left atrium, that you are going through that coronary sinus. So making sure that they really understand that. The same thing with the 2-2 for the add-on for the LV and of course our transeptal puncture code. I remember back in the days when we didn't have that and it was, it was always, you know, how do we, how do we represent this? The mapping. We've got two codes for mapping, the 93609 and the 93613 and most reports are pretty good to say 3D mapping was performed. If you're not saying the words 3D mapping and you're naming the type of machine that you're using, make sure your coders understand that that is what you use to conduct a 3D map and it's always better to just say the words 3D mapping. And then the 93623. Now we'll talk a little bit more about this one as we look at some of the ablation codes. That one is probably, I don't know, Nicole, I imagine you would see, you know, most discussion about this one as well because if you're performing this with an EP study and you're using it to try to prompt or, you know, using the medication, the isopril or whatever, and then doing pacing and recording maneuvers, that's pretty clear. But with an EP study, it really gets confusing. So we'll talk a little bit more about that in a second. Next slide. So we've already talked a little bit. Oops, I may want to go back one. We talked a little bit about bundling. Yeah, it was really kind of 2013 that that really started with EP. Of course, we saw some of it start in 2009 with cardiology in general. And there's a lot of things that can trigger, you know, bundling. You know, the AMA has this process along with CMS and the RUC where they look at codes and say, okay, these are ones frequently build together. These are one where we've seen an increase in utilization. These are ones that haven't been looked at. And since the Harvard studies, you know, way back when, well, it was a combination of kind of all of those that eventually led to a lot of our ablation procedures. And we saw a lot of changes. So what you're going to be able to build separately, and what is bundled is now determined, you know, by these new coding pairs and coding guidelines. And in a general sense, when the codes go up for a RUC review, the Relative Update Committee, it's really hard to come out of that committee and gain ground. It's more likely that you lose a little ground. And I can show you what I mean here. So go to the next slide. So if we look at the history here, any of you who've been in EP for a while, you can see in 2012, it was pretty nice. We had the EP study and an SVT ablation. You can see these are physician work values. And then everything else still added on to that. 2013, we had, you know, we did get another code for an additional ablate, an additional arrhythmia after we've done the first one. But then we fast forward to 21. Now look at what starts happening to our work RVUs. And more bundling occurs. So what we saw in 22, you know, you can see that, yes, from 21 to 22, the SVT ablation, we did see the additional bundling of the coronary sinus catheter, as well as the mapping. So that, you know, leaves, it really changes, you know, what our, our total potential work RVU and reimbursement are for those codes. Next slide. So it wasn't just the SVT ablation, got us in the AFib ablations too. So you can see, you know, if we go back to 12, look at that nice work RVU gets chopped almost in half. And now look at where we are. If we look at work RVUs for 21 and 22, you can see more bundling occurs, and it really gets difficult. And then in 23, we didn't see additional bundles, but we did still lose ground on those work RVUs. Next slide. I think the one that really hurt the most, look at these VT ablations back in the good old days, you know, used to get a 64 in that work RVU. Then we got some bundling, some changes cut almost in half. And then in 21, you can see more bundling and a little more decreases. So really what we want to do is make sure that everyone, you as clinicians, physicians, as well as your coders, understand how to document and code so that you're not leaving any revenue on the table. We need what we can get. So we want to build correctly and accurately. So we're going to talk a little bit about that. And Nicole and I'll chime in with some of the areas that we know seem to be most prone to problems. Next slide. All right. So if we look at, you know, 2023, this is where we saw, you know, there's no additional bundles, but we did have that additional work RVU reduction. So went through that process again, and both ACC and HRS argued that, hey, Ruck, you know, you took it down too low. And, you know, tried to argue that, you know, this process did not work for us. But what was really scary is Medicare had proposed to take it down even further. Ultimately, they accepted what the Ruck accepted, but we did still see that final little bit of knockdown. Next slide. So let's look at, you know, some different ways. When I mentioned earlier that I hope you're involved in the process that says, you know, here's how the physicians and the coders can work together. What I've shown you here on the left, you'll see is a yellow sheet. I think this is so easy, and I use it when I'm reviewing and doing auditing and coding these cases, because it reminds me right there, you know, where it lists that SVT ablation. We've got it in parentheses, what it includes, and then the most common things that may be added on right underneath it, real easy for the physicians to check it and check, check and or the coders or to translate that into an electronic system where you can see here that the descriptor reminds the clinicians what to do. They click this and then it goes electronically to the coders. Now what we have in place where I work is this then discrepancy log at the bottom and if you don't have something like this at least try it for like a month just to make sure you're all on the same page and you're interpreting reports and you're documenting well because what this does whatever the physician says build this the coder is then reading the report and from that report saying okay I agree and I also see this and or saying I didn't see what you you said to build this I don't see it. So that anytime there's a discrepancy that goes back to the physician so that you know what is getting billed and what's not and if you disagree you guys can learn from one another and or have the opportunity to just exchange information. So these are just two possible ways of doing it. Next slide. This is a nice tool. Nicole I'll let you tell us a little bit about this one. Yeah so thanks Linda. As you see in the presentation you'll see some of these these are what we call our quick cards and these are available under the resources and tools in the Medaxium RCS hub on the website and this is just to use as cheat sheets. These we have for many different modalities and again it's just another tool that you could have available and we know that the coders use these but many physicians like to have these also as references. So we did make them pocket cards at one time but with our electronic world what we've seen now is many physicians will take a picture of it and have it on their phone. So there's ways to do that. So yes these are available and definitely something that's helpful with the process. Great. All right SVT ablation. So as you can see kind of we don't need to read the whole code. We know what needs to be there. Each of those things that we've talked about being bundled you can see very clearly it includes what it includes and what it doesn't include. One of the things I would mention to you is that the transeptal puncture coat is separately billable here and keep in mind that that additional mechanism it can be billed up to two times. Now we'll we'll talk about that. You can see that listed underneath there that 93655 ablate a discrete mechanism. So we do want to be on the lookout for that and have you help alert us when you are ablating more than one source of SVT or more than one rhythm itself. Next slide. Next we have the AFib ablation. So this one now it's including that mapping, the transeptal puncture, the the placement of the LA catheter. One of the things here you know that that the if we look at doing more than one transeptal puncture that can be billed. So keep that in mind that if you do need to do a second one and then it gets really important if you are doing an additional mechanism you'll see the codes there. You've got a 93657 as well as a 93655. Now you'll see there that those codes are going to change based on what is that additional mechanism. Is it an additional AFib or some other arrhythmia? So it gets really difficult if what you say in your note is atrial tachycardia because what we're looking for is what kind? Is it fib? Is it flutter? Is it something more? Because that helps us choose the code. And if you do need to also do that LV pace and record you can bill that separately. Next slide. The BT ablation. This is going to include pretty much you know whatever you're going to do with it. Here too if once you've completed that BT ablation of course all of these are the EP study and ablation if they're done on that same day you can still bill that additional mechanism. Next slide. So the AV node ablation. This one I do see confusion on from time to time. We want to bill this one when you truly are creating a complete heart block. So if you're doing an AV node modification and you're not creating the the heart block then you would not want to bill this one. Now I know that in a lot of cases we're putting the device in then ablating the AV node. Should you do it in the same day? Both are separately billable. The device procedure is always going to be billable if you do it on the same day. Next slide. All right so look at this 93655. So here's that additional discrete mechanism distinct from the primary rhythm that's been ablated. This is probably the one that I see most often missed. So once you've ablated that primary site and you still have another tachycardia that's there of some sort and you're going to pace and record maybe even use some medication to help define it and then ablate that one we need to add this code. Now payers will frequently ask for the medical records from this so I love to see or you've got it you know additional ablation you know documented and blocked in your report. If you've ablated one that was maybe in a slow or fast pathway and then another arrhythmia emerged so we can see that yes it took shutting down that first one for you to see that there was another one and then you went on to address that one. So how you put this in your note give it its own little paragraph give it its own little heading make it clear that this is in addition to the first mechanism that you ablated. You can see here that this is distinct and if you go to the next code now we have that we're I'm sorry the next next slide now we have the code that's for an additional of atrial fibrillation after you've done the primary a fibrillation. So whether you do you know the pulmonary veins first and then maybe you know you've got to do that wide area and or you're doing a roof line or you do the roof line the order that you do them is completely irrelevant if what you're treating is in another mechanism of that fibrillation. So that's where we really really need you to make sure you don't say tachycardia because it's been more difficult for the coder to make that distinction of what was it and do they add this code after the atrial fibrillation or do they add the other code. Next slide. So this I have to give a shout out to my EP teacher which is Dr. Eric Prostowski. Back in 13 when the codes were bundled I was trying to understand this whole mechanism thing and you know I scheduled a time and said have you got 15 minutes just make sure I get this right and he was kind enough to sit down and just draw this for me and I this is where things were and where you kind of looked you know at least in 2013. But I have used this ever since I've even sent it with some appeal letters to basically you know say to the payers look we have laid it over here and then here. These are different places these are different mechanisms and I use it often with coders. So to those of you physicians if you've if you don't even know who your EP coder is please introduce yourself and it's wonderful if you take the time to work together to help understand this. So just a shout out to my to my teacher here. Next slide. So 93623 we talked about this. This one is probably the most highly contested code that I have seen in a lot of organizations. For whatever reason a lot of compliance people will look at this and say they oversimplify it. They take it down to no you can't code medication testing if you do the ablation first. That is so wrong. What you know as you know you you may do the ablation and then you use the medication to confirm that the medic that that it really worked that you blocked that. Okay now that's included that is not separately billable. But if you do that ablation you test you test post that looks good. Now you go to another area and you may need to use medication then. So you're using medication in combination with additional pacing uh and recording. That's the key. You have to put that emphasis on your in your note that not only did you you know you may have tested the efficacy of the ablation by using medication. But you now used it to also hunt down another one. You've got to show those additional maneuvers. That's what makes it billable versus included. So watch this. You know that's one of the ones what I would suggest to you. You know if you feel like you know I'm not sure I'm always getting credit for that. Ask your coders to say you know give me give me a report that shows all my CPT codes billed and the units in which it's billed. And look for this one. Also look for those add-ons. The the two additional mechanisms. See what the volumes are that those have been billed. Look for those and just see if they look right. And if not try to sit down together and talk through that. Next slide. So cardioversions. This one too gets confusing. This one is so important in your documentation. You know patient was scheduled for a SVT ablation. You know it was transferred to the table. Upon arrival to the lab the patient was found to be in atrial fibrillation. It was decided to then cardiovert the patient in order to perform. That's a billable cardioversion. So key to this is that they arrived in the lab already in that arrhythmia and you needed to do something with that arrhythmia in order to then do what you planned on doing that day. If you happen to while you're in the EP study you know the catheter tickles the patient into an arrhythmia or something. If that's not that's not a separate billable. And of course if you caused it you can't bill to stop it. So the only time you're really going to be able to bill that in the lab is when you document very clearly that the patient arrived to the lab in that arrhythmia and you needed to cardiovert in order to do what was planned. Next slide. So let's look at this documentation here. And what I wanted to point out I'll give you a second to kind of read up to it but you can see that we've done the atrial fibrillation ablation and then just below that where the red arrow is pointing to it's talking about that adenosine was administered to assess the veins with persistent bi-directional block no evidence was found. All right that's inclusive that is not going to be separately billable. But now look at our next paragraph we've got now atrial flutter ablation that that was noted after the transeptal puncture was performed at the left atrium demonstrated passive activation with that isthmus we've got the the 3d activation. So this is one where after we build the first one we've got the atrial fibrillation no separately billable and then an additional arrhythmia. Next slide. So this one I want you guys to use the QA box to answer. So take a look at this one. So read this go through this one a little bit. You can see we've got that that patient with persistent afib she's been ablated once they're coming back in she's in sinus rhythm starting the the ep study. Go to the next slide. All right we've got the intracardiac echo the transeptal puncture the mapping got the pulmonary vein ablation let's go to the next slide. This is where I want you physicians and coders to pay attention to this one and what I'd like to see you type in the QA box is are you going to bill an additional arrhythmia after the atrial fibrillation ablation and if so are you billing one more two more three more type your answer there in the question box and let's see what we see. I'll give you a second to read that. All right. We have any answers coming in? I don't see any. Oh, come on. You guys weren't ready for it to answer it, huh? Well, I just got a brave person. They said that they see three here. All right. So let's look at this. Now, I can tell you anytime you add that additional code, you're going to expect to see the insurance company ask for documentation. So let's get out of this first paragraph. We can see that we've looked at this. We've got additional posterior wall isolation noted. All right. No evidence of reconnection after administering Isopril. Now we're going on. We've got right inferior pulmonary vein form activation mapping on two separate occasions with the focal atrial tachycardia in the area of the scar in the low posterior septum. And we ablated there. And now what do we have? We've got another left atrial posterior septum. So the way this is lined out to say additional arrhythmia and then a substrate ablation, that's really good to point out that, yes, not only is there the atrial fibrillation ablation, but now it draws your eyes to those two paragraphs. And it could be more clear. I can tell you this one got downcoded by the insurance company to two. I think we can argue three. But it's really important to make that super clear in your documentation so we can fight and get you reimbursed for those extras. Did we get some other answers come in there, Nicole? Yes. So we got a couple that said that they would code one additional. So Linda, when you're talking about three, you're talking the primary PBI ablation. That's one. And then tell them your number two and number three. The low atrial, that posterior septum, as well as the atrial lobe, where you could also say is potentially that wall. Is that one yet another or is that part of the AFib ablation? That's what the insurance company argued. But getting those two, we clearly were able to support that. Okay. So I hope that helps a little bit to point out some of those things. Next slide. We've got device procedures. Before we start, I was just going to, we have two ablation questions that came in. So I think if we pause just a bit before we head into this section. Sure. When you're doing an AV node ablation and the physician, if they do not specify complete heart block was achieved, what do you recommend folks should build if they do not build a 93650? What has been your experience with that? Well, using the SVT ablation, and I've also seen people build the 5.0 with the 52 modifier to say it was reduced. And I went on and I've seen people say, well, then I'll use an unlisted procedure code. So it's not that what's clear is you bill it when you ablate the AV node. When it's the modification and it is not creating heart block, then I've seen people argue in different ways. What's your experience been, Nicole? Yeah. A bit of the same, you know, it's interesting. Anytime you get into some of these you get into, you put the 50, you know, the reduced service on it, you go unlisted. And I really think it's what your comfort level is and how your physicians and the physicians on the ground best describe the procedure. And I think that's the advice we generally give, but normally we'll see folks doing just what you said, either with the 52 or, you know, they'll, they'll look at the other ablation services to see if it fits into one of those as well. Yeah. And I guess for the benefit of the physicians listening, the 52 modifier is a procedure that was modified by reducing whatever is described by the CPT code at your election. So you chose not to completely finish what you were doing. The 53 modifier is similar. You still didn't completely finish the description of that code, but the reason you chose to not do it was because the patient was becoming unstable and it was unsafe for you to continue to do it. So that's just a little bit of coding speak, I guess, on the, on the differences between a 52 and a 53 modifier. Yeah, this is one too, that comes up pretty often. You know, we understand that 3d mapping is bundled, but if they're using regular mapping, do you see it build? I think we get asked this a lot. Well, what if I just build the 2d mapping or the, you know, regular mapping? And, you know, I think I'd love to hear your opinion. I know we're pretty aligned on this one. Yeah, it doesn't matter either one. And I think, I think what there's going to be is a correction in the parenthetical notes this next year that both codes will be listed there. I think there was an oversight where the code was listed in one and not the other in the parentheticals, yet the code description states it either way, if you look at the beginning. So there is a slight description, but if it's intended to include mapping, it's intended to include either mapping. Correct. And just one clarification, when we're doing those PBI ablations, those additional mechanisms tend to often cause us a bit of headaches. When you see them have an a flutter, you would it be, you know, we have someone asking which additional code it would be. And I know sometimes that gets confusing in the documentation with fib and flutter. So really having that clearly documented does help. So I will give that tip to the providers. But what do you normally see with that a flutter and those a fib ablation? Yeah, a fib is a fib, flutter is another tachycardia. So I would use the additional not remaining atrial fibrillation. Yep, fib is fib. And if you call it flutter, tachycardia, anything else, we're going to go with the additional mechanism, not a fib. Well, thank you. All right. Well, let's move on to device procedures. We appreciate all the questions coming in. Yeah. All right. So this is the EP billing sheet that we sat down and came up with in my group. And I think it really kind of illustrates well, your options when it comes to pacemakers or ICDs. You can see we've, you know, we've had some bundling occur here too. You know, we used to be able to build some other things separately, not so much anymore. So now we kind of broke it down this way where we're looking at, you know, pacemakers, ICDs, and really the four ways to kind of think about it. So Nicole, I know you've got a card for this too, as a reference. You want to show that one? Yep. Yep. So I think Linda, we start off with the categories. Yeah. Yeah. Okay. Sorry about that. That's okay. No worries. We'll, we'll dive into this. So when these FERT codes were originally changed, I remember spending time with Linda and Margie. So some of you will know those names on the phone. And of course we have Linda with us talking about how can we really look at this and get it straight in our minds. And really looking at it in four categories is the easiest way. So new device implants. So strictly a new device that includes leads. And when you're, when we're talking about leads, if you're doing an LV lead placement, it's important to remember there's always an add on. Then you have our simple generator changes, which means end-of-life generator. They're just going to go in, do a change. It includes the removal. It includes the insertion. Of course, if you add that LV lead, you always want to remember we have separate codes for that. A generator change plus a billable right-sided lead procedure. When this occurs, you do not use the generator change codes because you had a right-sided lead procedure. So you bill for the components performed until you've described the service. So Linda's going to dive a little bit into that and what we mean by that, but you're going to bill that new implant code and any other procedures that would not be bundled into that service. The leads attached to a previously placed generator. This one is probably the one that we see the least I would say, or I see the least, and I'm sure unless you have surgeons putting in some of your devices, but first time leads that have been attached to a generator. So this is when they may have had a generator placed by a surgeon and then the EP physician or someone would place the leads. Pretty rare that I see this. I don't think I've seen it in the last couple of years for sure, but there are some areas I'm sure it comes up. All right. And then what's always included? So venography for lead placement is always included. So if it's performed, it's considered inherent. And this is just some of the guidelines around that and why it means that it's inclusive. And really it's around when it's for that contrast injection, venography or road mapping or any kind of guidance, it is inherent to that procedure. Just a reminder, our pocket revisions, that was changed to the word relocation only. So this is when you truly are moving the pocket from one side to another as an example. So you can only bill these codes for relocation of a device. And then lastly is our device programming and reprogramming. I know we see this sometimes bill, particularly when our physicians are checking their billing sheets, they will check that they did programming at the time of the device. It's also considered an integral part of that procedure. And then if you're doing the periprocedural device follow-up codes, any of those are not billable at the time of that device implant or EP procedure. Oops. Sorry about that, Linda. Then lastly, our code for DFT testing is a code that is billable with our ICD implants. The most common one is the 93641. And this one is at the time of that initial implant. And what I will tell you is there's been some change in the clinical guidelines. So we often do not see that 401 billed as much, pretty rare with our ICD implants. There are times where we do see it, but it used to be a known that you were going to do that DFT testing, but now we don't see that as much. And then the 42 is usually used when the patient's brought back at a later date, not on that implant date. So that's why we don't see that one. We didn't see it before, unless they were really bringing them back only for that at a later date. Right. So Linda, take us through our four categories. Yeah. Thank you, Nicole. And truly, I think it's, it's pretty nice to be able to look at this sheet or I got ahead of myself. MedAxiom's got a sheet as well that we'll show you, but you know, I think it lays it out really well here where you've got the single atrial lead, which we don't see a whole lot of a single ventricular lead or a dual. So with pacemakers, it matters when we pick our system code. And that's what these codes are system being defined as both a lead and a generator going in, in the same session. So you can see, it depends on where's the lead versus an ICD. With the ICD, it's either a single or dual. There's no distinction when you're putting these in. So keep in mind that, you know, the ICD, it doesn't matter. And you'll see that the LV lead, the 33225, if you're placing that left ventricular lead, that same code is used regardless of whether you're attaching it to the pacemaker system or to the ICD system. And when that's done at the time of an initial device insertion, now you're going to add that because this is any time you have a procedure that involves both the lead and the generator. Okay. Next slide. So then we've got our second one. This one causes a little bit of confusion. These are generator change only codes. These codes were addressed because CMS made us address this commonly used coding pair of taking out the old, put in the new. So in response, new codes were developed. And you can see that this describes strictly that straight generator change. You didn't do anything else but that gen change. So you can see how those are broken out. You've got a generator change. This is for taking out the old, putting in the new, whether it's a single atrial or ventricular and or biventricular, and then device type, pacemaker or ICD. Now, you'll notice here that you might be doing that generator change. And let's say that you're taking what was a dual ICD, you're taking that one out, and you're adding a left ventricular lead. Now what do we do? Okay. So these codes represent that straight gen change only. You're just switching out the generator. Okay. So go to the next slide. This next one is when you have a billable right-sided lead. All right. So this is when the codes change. So if what you're doing when you do that change is to also, maybe you're switching out one of the right-sided leads. Now, if all you do is cut and cap it, okay, you can't bill for a lead removal if you only cut or cap it. You can bill if you actually remove it. Now, when you remove a lead, it doesn't matter how you remove it. If you're removing it with a snare or a tug or a weight or a laser, it's lead removal by any method, but it does have to be removed versus just being cut. So with a lead removal, now you're going to have a billable procedure. So now it's not a straight gen change. We have a billable right-sided lead procedure. So we are going to bill for taking out the old generator. We're going to bill for removing that lead, and then we're going to bill for what we put back in because we're putting in a lead and a generator and or system. So that distinction is straight gen change or a billable right sided lead procedure. And I've got an example of that in a document too. So, next slide. So, you see here, we've got that generator change, plus a right sided lead procedure. So as long as it's billable. Now you're going to, you know, bill for what you did, what you took out, generator removal, lead removal, and or what was it pacemaker ICD. And then what did you put back in. So you can see examples there at the bottom going across the bottom. Let's say you had that RV pacemaker gen change, plus you put in a new RV lead. If that leads capped, well then you're not going to build it. So you'd build that 33234, and you build the generator removal, and the fact that you put in a generator and a new lead. You've got that RV pacemaker that's being converted to a biventricular ICD, you take out the old, you put in the new with the left ventricular. Let's go to the next example. Next slide. It's getting tighter. Oh, there we go. We've got this one here so attaching leads to an existing generator. I would, I would suggest that you run a, you know, ask your, your billing folks to run a report and really make sure you're not using these much as Nicole mentioned earlier. These are rare, and I have seen coders mistake these that these are used only when the generator is there. And I'm sorry, got it backwards. When the leads are there. And now you're connecting them to a generator for the first time. And as Nicole mentioned it's used very rarely the times that I've seen it used most are on kids that you know they've got some time of congenital condition and while they were maybe having a procedure by the surgeons to address that they knew the time was getting to where now they're going to be more active and now they may need that device. So they go ahead and put the leads in. And then you would bill it this way. When they go to the lab and get, excuse me get connected to the leads for the very first time. So you're probably not doing a lot of these request that report take a look at it, make sure you're not building a lot of these. Next slide. So, let's code this one together. Let's look at this. We've got an EP study along with a cannabinoid challenge, and an ICD implant. As we said before, if you are doing EP studies and devices in the same setting or ablations and devices in the same setting those things are not bundled. So you can build both. So take a peek at this. We've got patients being evaluated for potential Bergada. You can see we've got the EP study. Got attempting pace from the high right atrium patients got a left bundle branch block at the RV apex, we're not able to induce arrhythmias. So now they decided to try some for cannabis. So they've done that. They do see that now at this point, they are going to go ahead and need that device. So now they're going to look at that ICD implant. Next slide. All right, so we got our ICD implanted the venogram as we, as we learned before, is not going to be separately billable. But we are still going to build for that ICD implant, as we talked about doesn't matter, single or dual 33249. And what else are we going to build. We're going to build that EP study, the 93620. And we're going to build that medication. The 93623. So hopefully that's what you came up with as well. And how to code this. Next slide. Okay, so this one actually came up recently. I'll let you look at this one. And what happened was the coder sent back something that was different than what the physician had indicated on that discrepancy sheet. It got sent to me to say, okay, I don't know if this is right, I need to understand it better. So this one illustrates really well what I was talking about before, about, yes, whether or not you have that billable right sided lead, having a billable right sided lead procedure changes everything. So you can see this one that they had that RV lead was removed from the old generator attached to the new one. They've added the LV lead, and the RA lead was then attached to the device that was in the pocket. So what do we end up with, we've got a dual chamber ICD, adding an LV lead, and we had to change the generator to accommodate that. So we've got the gen change code, we've got that straight gen change code, plus the addition of an LV lead. So the correct coding is there in that top box, the 33264 for the gen change, and the LV lead insertion adds on to that. Now, had they done something with that RV lead. Let's say that they had actually removed the RV lead. Now look at how that changes the coding. You would bill for removing that RV lead, then you get to remove bill for removing the generator. Then what you put back in is the insertion of a system, the 33249, and then the LV lead, the 33325. So that's the impact of what I was talking about earlier of how it really changes the coding. When you also have the billable right sided lead procedure in that case. Next slide. So here's just some of those miscellaneous codes. This is another one. I think I must have went 10-15 years before I saw my first case, a 33218. I was doing a review for a practice and I saw that on their list of CPT codes and I was like, really, I want to see that one. And by golly they did, they had some tape, taped it up, fixed it. It's a little more common now for whatever reason. The LV leads, you can see we've got the insertions there. We've got repositioning. What we don't have is removal of an LV lead. And, you know, that's not something that we have. And there's really not much we can say except that we just don't have a code for it. Typically, there is something more being done in addition to that. And I've seen people, you know, maybe try using an enlisted or adding a 22 modifier to say this is above and beyond what I normally have to do in this case to what else they did bill to say this was more and then you explain what that additional was. But we don't have the removal of an LV lead available to us as a code. Next slide. Moderate sedation. Here you count only that skin to skin time with the patient. The fact that, you know, that they may have been sedated a little bit before and you stepped out or in the procedure, you're in the control room doing something else and the patient still, you know, you don't count that. You do have to say pretty much something as you see in the box here that that moderate sedation with continuous monitoring dedicated trained observer that is key needs to be a dedicated trained observer, and then that medication stop and start time. Continuous implantable defibrillators. Not much to say there except the codes change based on, you know, what, what are you doing you put them in or taking them out. We've got the rhythm monitors, same thing. And now our leadless pacemakers. Next slide. This is that sheet in full, and I would invite you to be thinking about any questions you might want to add, but this is the sheet you know that you know I showed you the yellow side that that's all the EP studies and what adds on the devices and the center, the miscellaneous I think we've talked about each of those the insertions and removals the repositioning cardioversions the individual codes and and Nicole I believe you've got a sheet as well that we've not seen for devices. Yes, so it looks very similar to our format that you'll see on those quick cards under the downloads as well so it's just another look at it for you. And then it goes into some of our subcutaneous, and some of the other information we have around some of our wireless stuff and some of the different codes as well. So we are at questions, and I'm looking Linda, um, I see a question. And this one I think has comes up with our procedures many of our percutaneous procedures, what about using ultrasound for vein access and device procedures. Well, that door is pretty much closed. The NCCI edits, the National Correct Coding Initiative edits. It does specifically name, both the EP studies and ablations, as well as device procedures as not eligible that routine use of ultrasound guidance is is inclusive. So if you're seeing places that are a little, take a different spin on that. I want to be a little more aggressive. You must have documented proof that you have captured those images, and that that you know that in your note that those images were captured and saved. And that's going to be key to not having it be routine. So if that's something you do every patient, every time. That's routine, and that's exactly what's bundled. Now if you tried one area, couldn't get through, tried another, couldn't get through. Now you're about to do your third stick, and you're saying okay we need ultrasound now. That is what you would want to document. And now you might have a pair that you could argue that this is not routine use. You're going to have to argue it because they're going to deny it up front, and they're going to request your notes, and your notes need to very clearly show this was not a routine, there was something very unique, because routine use, it's bundled. Yeah, yeah, definitely. And this is definitely one and I know as Linda and I do many of the physician education sessions we often get asked about if we do a complex procedure or more times required. What have you seen be successful in documentation and billing for that. Okay, so we're talking about adding the 22 modifier. The 22 modifier says this was above and beyond the usual. Okay, so now we've got a couple issues. As you well know, you know some SPT ablations can be done in 45 minutes others maybe three four hours. So the range of codes, the codes themselves are intended to cover that range. So think about your quickest think about your most difficult. Anything that's related to the equipment, or anything like that, that made it take longer, you throw that out that that doesn't count. You've got to have something that's very unique to this patient. Now, I've seen it work well when you chase down in like three and four different arrhythmias, and you know every time you ablated it just patient just went right back in. But what's going to be key, every time you use it. They are going to ask for your notes, almost every payer is going to ask for your notes. So, add in your documentation, a little paragraph at the bottom with the heading, special circumstances. That heading special circumstances, and whatever you dictate below that, that is your chance to plea your case. So you make your case for yourself. This patient's anatomy was very unique. You know this patient, you know, had a very complex circuit that not only required this we also had to know anything that you can say that is really unique to that patient. It takes you out of your most difficult case in a normal week or whatever, you've got to be a beyond that, and then clearly say what that is, and make sure that that's clinically more complex, not just a bad day in the lab. Yeah, and I think what we've seen on that as a couple of things they're going to always request your documentation before they, you know, pay for your claim. They're going to always look at that and then there has been rarely some success in getting anywhere from like a 15% to a 20% I've heard. So you'll get an increase on reimbursement. But what we have to remember for many of our physicians that are paid on productivity and work RV use that doesn't necessarily equate to that in work RV use so you'll get increased reimbursement. So that RVU piece comes into your compensation plans and is not more of a reimbursement by the carrier. So that's one that is often asked and, and obviously you know one of the things if you put a modifier 22 on the majority of your procedures. That will definitely be questioned and I'm sure your coders are definitely removing that as it, you know, is above and beyond your normal usual procedure. Well, I truly hope that that you've picked up some tips today, and Nicole and I were joking earlier is like we love working with EP docs. Well, all docs but I'm particularly partial to EP I have to admit I love EP, but maybe it's because you think in milliseconds, but you can hear something and go implement changes in lab, the very next day. So I hope that you've listened and you'll talk with your colleagues and, and you can think about okay so maybe we should change our template to say this, or are we all doing that, or coming up with something like that and then involving your coders, you know, learning to know who your coders are if you don't know, and being actively involved in that billing process. Absolutely. Well, we appreciate everyone joining us and again this recording will be available the handouts will be available as well on the website and the academy, so look for that and we appreciate all of you attending and look forward to future webcasts that will have, particularly in the device space, and would love to get some interactive webcasts with device technicians and things like that. So Linda and I've been talking about that. And then also tune into our heart talk podcast that has our brief tips. And I think those are very valuable we're getting ready to record two more of those so looking forward to that. So thank you very much Linda as always, and I hope you all have a great evening. Thanks everyone.

EP lab billing

EP studies

ablation services

coding and documentation

bundled services

accurate documentation

coding options

reimbursement

modifiers

device-related codes